Letters Lipid lowering drugs in diabetes Abstract was misleading Editor—The meta-analysis by Costa et al tackles clinically relevant issues by evaluating the effect of lipid lowering treatment in primary compared with secondary prevention and diabetic patients compared with non-diabetic patients.1 The authors’ conclusions as reported in the abstract may have important implications for guideline recommendations and marketing of statins. The abstract reports relative risk reduction as the measure of effect for the primary outcome. They seem impressive and reach significance. But we noticed that the absolute risk differences, in particular those in primary prevention, are much less impressive, and not all risk differences reach significance. The overall baseline risk in the non-diabetic population calculated from the event rate in the placebo group is 8%. The reduction that can be achieved through lipid lowering treatment in this group is 2%, reducing the risk of a coronary event to 6%. In the diabetic population the baseline risk is only slightly higher, at 10%. The absolute risk reduction in this subgroup is also calculated as 2%. However, this difference does not reach significance ( − 0.04 to 0.00; P = 0.1). The authors do not address this and focus only on their “positive” findings, expressed as relative risks and relative risk reductions. Relative effect measures cannot be interpreted without knowledge of the event rate without treatment.2 The abstract of the meta-analysis does not provide this information. In addition, a measure of absolute effect (the risk difference), the most natural statistic to use when considering clinical significance,2 is not reported in the abstract. The abstract of this meta-analysis therefore does not provide clinicians with sufficient information to guide their practice. Moreover, it seems to lack objectivity, and the conclusion may even be misleading. The BMJ’s editors should protect the journal’s readers from overoptimistic reporting that is not supported by the scientific data and safeguard the objectivity of abstracts published in the journal. 1272 1 Costa J, Borges M, David C, Carneiro AV. Efficacy of lipid lowering drug treatment for diabetic and non-diabetic patients: meta-analysis of randomised controlled trials. BMJ 2006;332:1115-24. (13 May.) Mieke L van Driel editor, Minerva Belgian Journal for Evidence Based Medicine Department of General Practice and Primary Health Care, Ghent University, De Pintelaan 185 UZ 1K3, B-9000 Ghent, Belgium mieke.vandriel@ugent.be Pierre Chevalier editor, Minerva Belgian Journal for Evidence Based Medicine Centre Universitaire de Médecien Générale, Université Catholique de Louvain, Belgium Competing interests: None declared. 1 Costa J, Borges M, David C, Carneiro AV. Efficacy of lipid lowering drug treatment for diabetic and non-diabetic patients: meta-analysis of randomised controlled trials. BMJ 2006;332:1115-24. (13 May.) 2 Deeks JJ, Altman DG. Effect measures for meta-analysis of trials with binary outcomes. In: Egger M, Davey Smith G, Altman DG, eds. Systematic reviews in health care. Meta-analysis in context. 2nd ed. London: BMJ Publishing Group, 2001:318-21. Absolute risk reduction is what counts Editor—Costa et al draw the principal conclusion that diabetic patients benefit more, in both primary and secondary prevention.1 But it is abundantly clear from their own analysis that the relative risk reduction was similar across all categories of patient The numbers needed to treat remain as expected, reflecting, as they must, the absolute baseline risk and the 22% risk reduction across the board. Costa adds nothing new in recognising that, all other things being equal, diabetic patients have a higher absolute coronary risk. So what does this study add? There are no new important clinical implications, for primary prevention in patients with type 2 diabetes. It confirms that we should not change our guidelines. Patients will benefit from lipid lowering in accordance with their absolute cardiovascular risk. We should continue to target treatment according to best available predictions of absolute cardiovascular risk. Progress will come from improving the targeting of those at greatest risk, the accuracy of risk prediction, and finding cheaper, safer, and more acceptable treatments. L S Lewis general practitioner Surgery, Newport, Pembrokeshire SA42 0TJ sam@garthnewydd.freeserve.co.uk Competing interests: None declared. Lipid lowering has ophthalmic benefits Editor—Lipid lowering treatment in diabetes has ophthalmic benefits.1 Diabetic maculopathy is a common cause of loss of sight in diabetic patients and is characterised by retinal oedema and lipid exudates. The use of atorvastatin in diabetic maculopathy has recently been shown in a randomised controlled trial to decrease visible lipid exudates and also to have a positive effect on the visual outcome of affected patients.2 This study also confirmed that exudates may reduce or resorb within weeks of starting statin treatment and even before or without the need for argon laser photocoagulation, and this has been our experience also. The Wisconsin epidemiologic study of diabetic retinopathy first identified an association between elevated serum cholesterol and hard exudates.3 This was confirmed in the early treatment diabetic retinopathy study,4 and the FIELD study showed a 30% reduction in laser interventions required in type 2 diabetic patients receiving fenofibrate versus the placebo group.5 We recently followed a case series of patients with type 2 diabetes in ophthalmic outpatients. We confirmed the dramatic anatomical resolution of retinal hard exudates that may result from modifying the lipid profile in patients with type 2 diabetes, although this may not necessarily be associated with an improvement in Snellen visual acuity, as Snellen acuity is a crude test of visual function. Statin treatment, and lipid lowering in general, not only confers primary and secondary cardiovascular protection but is an emerging and exciting adjunctive treatment in gaining control in exudative diabetic maculopathy, for which argon laser treatment has traditionally been the only treatment option. Hiten G Sheth specialist registrar drhitensheth@yahoo.co.uk Sher Aslam senior house officer Nigel Davies consultant Department of Ophthalmology, Chelsea and Westminster Hospital, London SW10 9NH Competing interests: None declared. 1 Costa J, Borges M, David C, Carneiro AV. Efficacy of lipid lowering drug treatment for diabetic and non-diabetic patients: meta-analysis of randomised controlled trials. BMJ 2006;332:1115-8. (13 May.) 2 Gupta A, Gupta V, Thapar S, Bhansali A. Lipid-lowering drug atorvastatin as an adjunct in the management of diabetic macular oedema. Am J Ophthalmol 2004;137:675-82. BMJ VOLUME 332 27 MAY 2006 bmj.com Letters 3 Klein R, Klein BE, Moss SE, Davis MD, DeMets DL. The Wisconsin Epidemiologic Study of Diabetic Retinopathy. X. Four-year incidence and progression of diabetic retinopathy when age at diagnosis is 30 years or more. Arch Ophthalmol 1989;107:244-49. 4 Chew EY, Klein ML, Ferris FL 3rd, Remaley NA, Murphy RP, Chantry K, et al. Association of elevated serum lipid levels with retinal hard exudate in diabetic retinopathy. Early Treatment Diabetic Retinopathy Study (ETDRS) Report 22. Arch Ophthalmol 1996;114:1079-84. 5 The FIELD study investigators. Effects of long-term fenofibrate therapy on cardiovascular events in 9795 people with type 2 diabetes mellitus: randomised controlled trial. Lancet 2005;366:1849-61. End of contract for Drug and Therapeutics Bulletin Cost cutting, or worse? Editor—The Department of Health stopping funding of the Drug and Therapeutics Bulletin is a disgrace.1 On the same page Hitchen reports that over a quarter of a million admissions to UK hospitals related to adverse drug reactions.2 There is no doubt from research here and in the United States that a substantial proportion of these, perhaps most, are avoidable. Presumably then prescribers’ knowledge of drugs has room for improvement, and adding resources would seem more logical than removing one of the most important ones. Naturally, cost constraints are given as the reason for this action, but the cynic might wonder. Does the National Institute for Health and Clinical Excellence (NICE) want an independent source of information that may disagree with its conclusions? And does the pharmaceutical industry welcome a publication that often says that “new” drugs are not so new after all? If they are content with that perhaps they could fund the continued distribution of the bulletin, at least for a time. Michael Schachter senior lecturer in clinical pharmacology St Mary’s Hospital, London W2 1NY m.schachter@ic.ac.uk Competing interests: None declared. 1 Brettingham M. Department of Health ends contract with drugs bulletin. BMJ 2006;332:1109. (13 May.) 2 Hitchen L. Adverse drug reactions result in 250 000 UK admissions a year. BMJ 2006;332:1109. (19 May.) Bulletin is value for money Editor—The failure to renew the subscription to the Drug and Therapeutics Bulletin is undoubtedly a short sighted mistake.1 Does the Department of Health want general practitioners and specialists to rely on potentially biased sources of information? At a price of £1.4m per year, this publication has done more good than any comparable NHS expenditure. I hope that the Department of Health reverses this damaging decision. BMJ VOLUME 332 27 MAY 2006 bmj.com Trevor Watts senior lecturer Department of Periodontology, KCL Dental Institute, Guy’s Hospital, SE1 9RT trevor.watts@kcl.ac.uk Competing interests: None declared. 1 Brettingham M. Department of Health ends contract with drugs bulletin. BMJ 2006;332:1109. (13 May.) Choices Editor—In the February 2005 issue of the Drug and Therapeutics Bulletin I learnt that the cost of oxycodone is four times the cost of regular long acting morphine, without any special advantage in terms of efficacy or tolerability. I adjusted my practice accordingly. The bulletin’s opinion has been confirmed in a recent meta-analysis from the Marsden Hospital in London and Bristol University.1 I could quote many other examples like this, which leads me to ask: if saving money is the issue, why kill one of the few practical and respected sources of rational prescribing?2 The logic supporting this choice seems to me as puzzling as extending pub hours to reduce antisocial drinking. Piero Baglioni consultant physician Prince Charles Hospital Merthyr Tydfil, Mid Glamorgan CF47 9DT piero.baglioni@nglam-tr.nhs.uk Competing interests: None declared. 1 Reid CM, Martin RM, Sterne JAC, Davies AN, Hanks GW. Oxycodone for cancer-related pain: meta-analysis of randomized controlled trials. Arch Intern Med 2006;166:837. 2 Brettingham M. Department of Health ends contract with drugs bulletin. BMJ 2006;332:1109. (13 May.) Australian Prescriber was resurrected Editor—The Drug and Therapeutics Bulletin is too important to disappear.1 If there was a need for a drug bulletin in the 1960s, that need must be greater now, considering the greater choice of drugs available. Health professionals are busy people and so appreciate receiving independent assessments of new drugs. The evaluations of the Drug and Therapeutics Bulletin are read by everyone, from medical students to clinical professors; even policy makers. The related publication Treatment Notes is now providing helpful information for patients. The Drug and Therapeutics Bulletin has also inspired other drug bulletins around the world. Australian Prescriber underwent a similar hiatus in the 1980s. Within a few months it was realised that if you do not have an independent source of information there is nothing to balance the advertising that bombards prescribers. Australian Prescriber was quickly resurrected and is now recognised as an important component of Australia’s national medicines policy. Although the central contract for the Drug and Therapeutics Bulletin may have ended, I am sure that fundholders and those responsible for encouraging good prescribing at the local level will continue to support the publication. They need to act now before the editorial team is disbanded. John S Dowden editor Australian Prescriber, Deakin, ACT 2600, Australia jdowden@nps.org.au Competing interests: JSD is the editor of a drug bulletin. 1 Brettingham M. Department of Health ends contract with drugs bulletin. BMJ 2006;332:1109. (13 May.) Inhaled insulin Evidence based or industry driven medicine? Editor—Morton-Eggleston and Barrett give a useful, timely description of inhaled insulin to coincide with the recent recommendations from the National Institute for Health and Clinical Excellence (NICE).1 2 But why issue an editorial by authors from the United States, a country not known for its wise use of health resources? And, why from an author heavily involved with Pfizer, the makers of the first inhalable insulin preparation (see competing interests)? A more balanced and less promotional editorial was published in the BMJ only two years ago,3 and the questions raised at that time—concerning lack of additional benefit, long term safety, lung complications, questions on patients’ preference, and the cost implications for the care of other patients— remain unanswered. In the same issue of the BMJ questions were raised in a commentary about the worrying and increasing influence of the pharmaceutical industry in the academic research agenda.4 Should we not have the same concerns about industry driven medicine? Doctors working in the United Kingdom and striving hard to continue the, arguably, best health service in the world, tend to agree with the NICE recommendations and would be concerned with any change of opinion without further, non-industry based, evidence. H Alberti academic general practitioner Tunis, Tunisia hugh.alberti@newcastle.ac.uk Competing interests: None declared. 1 Morton-Eggleston E, Barrett EJ. Inhaled insulin. BMJ 2006;332:1043-4. (6 May.) 2 National Institute for Health and Clinical Excellence. Inhaled insulin for the treatment of diabetes (type 1 and 2): appraisal consultation documents. 2006. www.nice.org.uk/ page.aspx?o = 305474 (accessed 12 May 2006). 3 Amiel SA, Alberti KGMM. Inhaled insulin. BMJ 2004;328:1215-6. 4 Delaney B. Is society losing control of the medical research agenda? BMJ 2006;332:1063-4. (6 May.) Concerns remain Editor—Morton-Eggleston and Barrett conclude that the adverse effects of inhaled insulin are not clinically worrisome.1 Insulin is a potent mitogen and growth factor in the lung, leading to concerns that repeated 1273 Letters inhaled delivery of insulin results in supraphysiological alveolar insulin deposition which may result in adverse local effects.2 Several studies of the efficacy of the inhaled insulin (Exubera) in patients with type 1 and type 2 diabetes have shown a reduction in lung diffusing capacity (DLCO).3 4 Since lung function has not been altered in other studies of inhaled insulin, the manufacturers of Exubera have concluded that inhaled insulin is not associated with pulmonary dysfunction.5 Only one of these studies was of greater than two years’ duration, whereas the remainder were limited to three months. The chronicity of diabetes means that patients will require treatment with inhaled insulin for much longer than two years. Although inhaled insulin is currently licensed in adult diabetes patients alone, concerns about the long term effects of inhaled insulin are particularly relevant in young patients with adult type 1 diabetes, in whom inhaled insulin will be potentially administered for many years. Until long term safety data on the effects of inhaled insulin on pulmonary function are available, we should remain cautious. Niamh M Martin specialist registrar n.martin@imperial.ac.uk Karim Meeran consultant Metabolic Medicine Unit, Hammersmith Hospital, London W12 0HS Competing interests: None declared. 1 Morton-Eggleston E, Barrett EJ. Inhaled insulin. BMJ 2006;332:1043-4. (6 May.) 2 Hsia CW, Raskin P. The diabetic lung: relevance of alveolar microangiopathy for the use of inhaled insulin. Am J Med 2005;118:205-11. 3 Quattrin T, Belanger A, Bohannon NJV, Schwartz SL. Exubera Phase III Study Group. Efficacy and safety of inhaled insulin (Exubera) compared with subcutaneous insulin therapy in patients with type 1 diabetes. Diabetes Care 2004;27:2622-7. 4 Skyler JS, Weinstock RS, Raskin P, Yale JF, Barrett E, Gerich JE, et al. Exubera Phase III Study Group. Use of inhaled insulin in a basal/bolus insulin regimen in type 1 diabetic subjects. Diabetes Care 2005;28:1630-5. 5 Teeter JG, Becker R. The clinical relevance of inhaled insulin in the diabetic lung. Am J Med 2006;119:184-90. Spain’s high rate of organ donation may hinge on local use Editor—Barber et al draw attention to the high refusal rates in the UK as a major reason for poor transplantation rates in the UK, and contrasts these with the Spanish rate for 2004 of 33.0 per million population (comparable figure for 2005 is 35.1/1000 000).1 A similar comparison for the refusal rate may be helpful. The UK transplant team’s figure of 41% refusals must be contrasted with an average for Spain of 16.8%, with regional data varying from 9.6% to 30.5%.2 Historically transplantation rates in Spain have been high in areas with a strong regional identity and lower in central rural Spain, although these differences are declining. Anecdotally, one reason for Spain’s low refusal rate may be a public belief that 1274 organs will be used locally and will therefore benefit people “like the donor.” One wonders whether the perception in Britain is that organs may be used at a distance as a result of central coordination, whereas the Spanish system ripples the offer of organs in a cascade. By contrast, the suggestion that UK coordinators are not as active as their Spanish equivalents in asking relatives for permission to use organs now seems unfounded. research purposes.1 They also underscore the high level of trust that patients place in their clinical caregivers to protect their interests in matters of clinical research. Graham Brack community pharmacist 10 Frances Street, Truro TR1 3DN graham.meagher@dnet.co.uk David Hill director Cancer Council Victoria, Carlton, VIC 3053, Australia Competing interests: None declared. Competing interests: DCW is a member of the NHMRC Working Committee on Privacy, which is chaired by DH. CC is director of the NHMRC Centre for Health Advice, Policy and Ethics, which commissioned this research. 1 Barber K, Falvey S, Hamilton C, Collett D, Rudge C. Potential for organ donation in the United Kingdom: audit of intensive care records. BMJ 2006;332:1124-7. (13 May.) 2 Data in graphical form. www.ont.es/Estadistica?accion = 2&id_nodo = 19&id_estadistica = 21&perfil = (accessed 20 May 2006). Australian public’s views on privacy and health research Editor—Attitudes to privacy in health research are often the subject of debate, however, surprisingly little data exist with which to guide policy. Addressing this gap, Barrett et al recently reported overwhelming support among the British public for legislation to make cancer registration compulsory and found high levels of acceptance for registries being used as sampling frames for research.1 Is this tolerance of research using sensitive health data a peculiarly British trait? In 2004 the National Health and Medical Research Council (NHMRC) of Australia undertook surveys of seven stakeholder groups (one of which was the Australian general public) to investigate attitudes to privacy in the realm of health and medical research.2 3 In a random telephone survey 192 out of 301 survey respondents (64%) were in favour of health databases being used for approved research purposes, and a similar proportion supported health research involving record linkage between two or more databases. Thus, most respondents were not sufficiently concerned by privacy to prevent research activities. Indeed, more respondents reported more concern about the confidentiality of their financial information (147 (49%)) than their health information (94 (33%)). Public attitudes to the use of disease registers for sampling potential study participants was explored through a hypothetical scenario in which researchers investigating hepatitis C sought to make contact with patients listed on a clinical register. When asked to choose their preferred mode of contact, 269 (89%) indicated that they wanted the initial approach to come from their general practitioner or clinic; only 29 (10%) preferred direct contact from researchers. These Australian data support Barrett et al’s finding of widespread public support for the use of health information for approved David C Whiteman NHMRC senior research fellow david.whiteman@qimr.edu.au Division of Population Studies and Human Genetics, Queensland Institute of Medical Research, Brisbane, Herston, QLD 4006, Australia Cathy Clutton acting executive director Centre for Health Advice, Policy, and Ethics, National Health and Medical Research Council, GPO Box 1421, Canberra, ACT 2601, Australia 1 Barrett G, Cassell JA, Peacock JL, Coleman MP. National survey of British public’s views on use of identifiable medical data by the National Cancer Registry. BMJ 2006;332(7549):1068-72. (6 May.) 2 Whiteman D. Privacy and medical research. Intern Med J 2005;35:441-2. 3 National Health and Medical Research Council of Australia. The impact of privacy regulation on NHMRC stakeholders. Canberra: 2004. www.nhmrc.gov.au/about/ privacy.htm (accessed 15 May 2006). Dame Janet’s disappointments Shipman case is a stick to beat the medical profession with Editor—The Shipman case is hardly relevant to the regulation of the medical profession since it is the job of the police to detect murder.1 It has been chosen, however, as a convenient stick with which to beat us. After all, the DVLA was not restructured when the “Yorkshire Ripper” was found to be a lorry driver, although his occupation allowed him to travel around the country murdering women. The tone of Dame Janet Smith’s opening remark furthers the damage to the profession; why should patients not have faith in doctors? It is valuable to them when being treated, especially as the doctor is often part of the treatment. It is also helpful to the doctor since to present the patient with a clear and balanced account of every factor considered in the choice of treatment is usually impractical. When revalidation is finally implemented, I expect very few patients will check their doctor’s score but will continue to trust the doctor as usual. More worrying is the expectation that Dame Janet’s recommendations would be acted on promptly and without further review, testing, or modification, and that this expectation is shared by influential academics such as Elwyn.2 While Dame Janet was used to dealing with medical mishaps in the course of her legal practice, this is not necessarily the best grounding in managing the regulation of the generally competent majority of practitioners. The lack of wide consensus shows that the design and implementation of a fair and effective regulatory system is not a simple BMJ VOLUME 332 27 MAY 2006 bmj.com REX FEATURES Letters The case of Peter Sutcliffe did not prompt restructuring of the DVLA matter; the General Medical Council has had this as its chief remit for more than a century, and if it were easy, it would have had something in place which would have weathered the Shipman storm, although probably not prevented it. Certainly the GMC must develop its system of regulation to meet reasonable contemporary expectation, now and in the future. However, to base this on a single case is as inappropriate as promoting a new treatment after one success, and we should be properly critical of unproved innovation. Gerald Freshwater occupational physician Hill House, Lerwick, Shetland ZE1 0EL freshwater@zetnet.co.uk Competing interests: GF is registered with the General Medical Council. 1 Richards T. Chairwoman of Shipman inquiry protests at lack of action. BMJ 2006;332:1111. (13 May.) 2 Elwyn G. Dame Janet’s disappointments. BMJ 2006;332:1161. (13 May.) Dame Janet’s indignation helps no one Editor—Has it occurred to Dame Janet Smith that the reasons her proposals might be so slow to implement are because they are not an appropriate solution?1 Of the changes introduced, most doctors know that appraisal is in practice both costly and ineffectual and that revalidation is likely to be a more grandiose version of the same. When, one wonders, would a High Court judge be happy to have a doctor sit in judgment of some of the very necessary reforms of her profession? Peter J Mahaffey consultant surgeon Bedford Hospital, Bedford MK42 9DJ mahaffey@lycos.co.uk Competing interests: None declared. 1 Richards T. Chairwoman of Shipman inquiry protests at lack of action. BMJ 2006;332:1111. (13 May.) It’s not that easy to keep an eye on each other Editor—Firstly, can we put Harold Shipman aside?1 2 What he did was horrible, but basing BMJ VOLUME 332 27 MAY 2006 bmj.com a system of revalidation on the actions of a psychopathic mass murderer is absurd. No matter what system is put in place, it will not stop the psychopath, just as all the fences in the world will not stop a suicide bomber. The whole problem with keeping an eye on one another is no one knows what we are keeping an eye on. What is a “good enough” doctor? We can all enumerate the qualities of a “good” doctor—compassionate, knowledgeable, in possession of clinical skills, and dependable with a healthy dose of common sense, for starters. But can we define the doctor who needs to be struck off? That is a whole different story. Sadly, and I am not surprised Dame Janet doesn’t get this as I suspect she inhabits the black and white world of the law courts, medicine is rarely black and white but a confusing number of shades of grey. For example, if a diabetic patient has a blood pressure of 140/80, am I a bad doctor, a good enough doctor, or a good doctor? What if said patient’s other indices are spot on? What if the blood pressure is a lovely 120/80, but she feels terrible and only keeps taking her pills because I insist? What if the blood pressure is 160/90, 200/100? I teach and struggle with just such dilemmas all the time. When should a student or resident be failed? Do I fail them for always being late? Do I fail them because they show up but don’t seem particularly interested? Do I fail them because their clinical knowledge appears to be a bit less than their peers? I don’t know. If anyone else does, I would love to hear from them. William E Osmun family doctor Mount Brydges, Ontario, Canada N0L 1W0 ted@smhc.net Competing interests: WEO is a doctor. 1 Richards T. Chairwoman of Shipman inquiry protests at lack of action. BMJ 2006;332:1111. (13 May.) 2 Elwyn G. Dame Janet’s disappointments. BMJ 2006;332:1161. (13 May.) Not so fast with vacuums and maggots as firstline treatment Editor—The statement by Thomas and Asaad, that vacuum assisted closure (VAC) and maggots should be considered as first line rather than alternative treatment in hard to heal, cavitating, intransigent ulcers with sloughy and unhealthy wound beds should not go unchallenged.1 Both are costly treatments for which there is currently a complete absence of robust evidence of clinical and cost effectiveness. Data supporting the use of VAC have been extensively reviewed by several jurisdictions independently, and they have reached the unanimous decision that there is insufficient research evidence supporting its use.2–5 Data from rigorous research evaluating larval therapy are even more sparse. Given the finite resources for health care, in advocating interventions of unproved cost effectiveness as first line treatments we are highly likely to deny other people far more beneficial (and cost effective) treatments, and simultaneously make it more difficult to undertake the research that is needed. Nicky Cullum professor Department of Health Sciences, University of York, Area 2, Seebohm Rowntree Building, York YO10 5DD nac2@york.ac.uk Competing interests: NC is chief investigator on an NHS health technology assessment programme randomised trial of larval therapy. 1 Thomas S, Asaad SS. Vacuums and maggots in orthopaedic surgery. BMJ 2006;332:1156. (13 May.) 2 Fisher A, Brady B. Vacuum assisted wound closure therapy. Canadian Coordinating Centre for Health Technology Assessment: Issues in Emerging Health Technologies 2003;44. www.ccohta.ca/publications/pdf/221_vac_cetap_e.pdf (accessed 19 May 2006). 3 Pham C, Middleton P, Maddern G. Vacuum-assisted closure for the management of wounds: an accelerated systematic review. Australian Safety and Efficacy Register of New Interventional Procedures—Surgical 2003;37. www.med.monash.edu.au/healthservices/cce/evidence/ pdf/c/991fr.pdf (accessed 19 May 2006). 4 Ontario Health Technology Advisory Committee. Vacuum-assisted closure (VAC therapy) for chronic wounds. OHTAC Recommendation 2004. www.health.gov.on.ca/english/providers/program/mas/ reviews/docs/recommend_vac_121604.pdf (accessed 19 May 2006). 5 Samson D, Lefevre F, Aronson N. Wound healing technologies: low level laser and vacuum assisted closure. AHRQ Evidence Report/Technology Assessment 2004;1-5. Access to emergency care in Palestinian West Bank Study seems not to have been critically appraised Editor—I peer review papers for some less prestigious journals: here are some observations on the paper by Rytter et al on the effects of armed conflict on access to emergency health care in the Palestinian West Bank.1 Was this week and were these hospitals representative? Were hospitals chosen as likely to yield anticipated results (selection bias)? Was hospital admission more likely to stimulate recall of delay than non-admission (recall bias)? When were questions about delay asked—and, critically, how were questions phrased? Could patients assessed as delayed by conflict have been delayed for other reasons (misclassification)? How were data obtained? What intermediaries were there between researcher and source—for example, interpreters? Was awareness of research objectives by interviewees or others likely to bias outcome? Could more serious illness implicit in admission have contributed to delay (confounding)? Were patients complaining of delay preferentially admitted to hospital? Were the baseline medical conditions different between the groups and did this account for differences in admission rates? Incidentally, were patient consent and ethics committee approval for access to data needed and obtained? “Delay” resulted in a difference in median speed of 2.5 km/h. What was the effect on the time taken to reach hospital? The authors assume that a reported delay significantly affected journey time, which damaged health. The facts available to the authors may support their conclusions—or 1275 Letters perhaps they just support their preconceptions. They have not provided information in a way that allows the reader to judge. As distinct from the paper’s stated conclusion, the higher admission rate suggests that reported delays (not, as stated, restrictions in access) influence hospital admission rates (not, as stated, the severity of the medical conditions). It is laudable that socially aware undergraduates undertake and publish research but it is incumbent on journal editors to maintain appropriate standards. 3 Richter ED The Barrier: protection of the right to life from incitement and terror in the Israeli-Palestinian conflict: an epidemiologic working paper. (30 pp; unpublished available on request). 28 February 2004. Submitted to International Court of Justice in The Hague. Humanitarian crisis in Israeli occupied territories Elliot Brown principal consultant Elliot Brown Consulting, Barnet EN5 2EZ brown_elliotg@yahoo.co.uk Competing interests: None declared. Methods were incomplete Editor—The study by Rytter et al on the effects of armed conflict on access to emergency health care in the Palestinian West Bank does not include any baseline comparison of emergency room admission rates, either from different time periods, other geographical areas, or similar healthcare systems.1 There is no discussion of acuity, case mix, age stratification, and other standard analyses of scientific measurement. Leonard Thaler health care association executive New York, NY 11219, USA lthaler@verizon.net Competing interests: None declared. 1 Rytter MJH, Kjældgaard AL, Brønnum-Hansen H, Helweg-Larsen K. Effects of armed conflict on access to emergency health care in Palestinian West Bank: systematic collection of data in emergency departments. BMJ 2006;332:1122-4. (13 May.) Interpretation of results is flawed Editor—The study reported by Rytter et al attributes a risk for added admissions to hospital to delays from checkpoints, detours, and curfews imposed by the Israeli Defence Forces (IDF) during January 2005—described as “a relatively calm period in the West Bank.”1 However, a review of their data raises some questions about the internal consistency and coherence of the findings and their interpretation. Of all 2228 contacts, 394 (17.7%) were delayed, and of these, 125 (32%) required admission to hospital, resulting in an overall risk of 5.6%. But 51 of the 125 would have been admitted anyway, based on expected risks of hospital admissions in people not delayed for military reasons. Therefore, 74 admissions—or 3.3% of all contacts—were specifically attributable to delays, which were self reported. Using the authors’ data on travel times, (18 km/h and 15.5 km/h in non-delayed and delayed groups), and estimated average trip length of 15 km, we estimated median travel times to be 50 minutes and 58 minutes, respectively. Although these estimates omit ranges, it seems a bit odd that a 16% increase in 1276 View publication stats BANKSY 1 Rytter MJH, Kjældgaard AL, Brønnum-Hansen H, Helweg-Larsen K. Effects of armed conflict on access to emergency health care in Palestinian West Bank: systematic collection of data in emergency departments. BMJ 2006;332:1122-4. (13 May.) Graffiti on the security barrier separating the occupied territories from Israel median travel time—an additional 8 minutes within the golden hour—should account for 59.2% of the 125 delays. These findings do not make a persuasive case for the role of IDF checkpoints, detours, and curfews in producing major delays in access to emergency health care. The period leading up to January 2005 was anything but calm in our region. From September 2004 to February 2005 terror attacks, originating mostly from Palestinian regions, killed 76 and wounded another 234 people, mostly Israeli civilians, Jewish and Arab people, and foreigners.2 The checkpoints—themselves not very safe areas— foiled other attacks and smuggling of arms. Now they are fewer, having been replaced by the barrier, an even more effective deterrent.3 Elihu D Richter head elir@cc.huji.ac.il Rony Blum Center for Injury Prevention, Hebrew University, Hadassah School of Public Health and Community Medicine, PO Box 12272, Jerusalem 91120, Israel Avraham Rivkind Department of General Surgery and Shock Trauma Unit, Hebrew University, Hadassah Medical Center, Jerusalem Competing interests: Over the past 25 years EDR has participated in investigations by human rights groups on the use of tear gas and the health conditions of Palestinian prisoner detainees, as well as initiated, supervised, and participated in joint Israeli-Palestinian projects to investigate and prevent epidemics of lead poisoning and asthma in refugee camps, and to assess the distribution and determinants of lead exposures of children in Israel, Jordan, and the Palestinian Authority. RB is a researcher in trauma and bereavement and interethnic conflict around the world. AR has overseen Hadassah’s trauma care during the past 15 years, which has provided care for all injured and provided training for Palestinian healthcare workers. 1 Rytter MJH, Kjældgaard AL, Brønnum-Hansen H, Helweg-Larsen K. Effects of armed conflict on access to emergency health care in Palestinian West Bank: systematic collection of data in emergency departments. BMJ 2006;332:1122-4. (13 May.) 2 Ministry of Foreign Affairs. Victims of Palestinian violence and terrorism since September 2000. http:// www.mfa.gov.il/MFA-Terrorism (accessed 6 April 2006). Editor—Why has there been so little international outcry about the humanitarian crisis in the Israeli occupied territories reported in the BMJ and by the Physicians for Human Rights Israel?1 2 It is stunning how documentation from international and regional human rights organisations, all pointing the same way (Amnesty International alone has issued 301 reports since September 20003), is ignored or dismissed as evidence of anti-Israel bias or of antiSemitism. It is hard not to conclude that behind this selective blindness is a view of the captive Palestinian population as not in the same moral universe. We should note with shame that the International Committee of the BMA, who are members of the World Medical Association (WMA, the international watchdog on medical ethics), has not raised in that forum the grotesque events unfolding in the occupied territories, still less challenged the persistent silence of fellow members, the Israeli Medical Association. The WMA is in violation of its own mandate. For the BMA International Committee, as members of the WMA, to ignore such massive and sustained violations of the Geneva convention, which guarantees a population’s right to health care, and not to challenge the silence of the relevant national medical association, is to demonstrate straightforward collusion. If this is not a form of medical malpractice then I have lost my bearings: it should be a matter for the General Medical Council. I call on BMA members to speak out where it matters, including at the annual representatives meeting next month. I would be happy to hear from members who feel this cannot go on. Derek A Summerfield honorary senior lecturer Institute of Psychiatry, Maudsley Hospital, London SE5 8AP derek.summerfield@slam.nhs.uk Competing interests: None declared. 1 McGreal C. Aid withdrawal is bringing health service in Gaza to brink of collapse. BMJ 2006;332:1171. (20 May.) 2 Report: Collapse of the Palestinian health system. www.phr.org.il/phr/article.asp?articleid = 338&catid = 55&pcat = -1&lang = ENG (accessed 20 May 2006). 3 Amnesty International. www.amnesty.org.uk/ We select the letters for these pages from the rapid responses posted on bmj.com favouring those received within five days of publication of the article to which they refer. Letters are thus an early selection of rapid responses on a particular topic. Readers should consult the website for the full list of responses and any authors' replies, which usually arrive after our selection. BMJ VOLUME 332 27 MAY 2006 bmj.com